Miljko Ristic

A novel technique for treatment of mitral valve prolapse/flail

References 1. Leal-Noval SR, Rincon-Ferrari MD, Garcia-Curiel A, et al. Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery. Chest. 2001;119:1461-8. 2. Rogers MA, Blumberg N, Saint SK, et al. Allogenic blood transfusions explain increased mortality in woman after coronary artery bypass graft surgery. Am Heart J. 2006;152:1028-34. 3. Lacroix J, Hebert PC, Hutchinson JS, et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med. 2007;356:1609-19. 4. Boettcher W, Merkle F, Huebler M, et al. Transfusion-free cardiopulmonary bypass in Jehovah’s Witness patients weighing less than 5 kg. J Extra Corpor Technol. 2005;37:282-5. 5. Redlin M, Koster A, Huebler M, et al. Regional differences in tissue oxygenation during cardiopulmonary bypass for correction of congenital heart disease in neonates and small infants: relevance of near-infrared spectroscopy. J Thorac Cardiovasc Surg. 2008;136:962-7. 6. Golab HD, Takkenberg JJM, Gerner-Weelink GL, et al. Effects of cardiopulmonary bypass circuit reduction and residual volume salvage on allogenic transfusion requirements in infants undergoing cardiac surgery. Interact Cardiovasc Thorac Surg. 2007;6:335-9. 7. Kotani O, Honjo O, Nakakura M, et al. Impact of miniaturization of cardiopulmonary bypass on blood transfusion requirements in neonatal open heart surgery. ASAIO J. 2007;53:662-5. Brief Communications

Surgical revascularization on the beating heart in patients with low ejection fraction

INTRODUCTION The subset of patients most likely to benefit from off-pump coronary artery bypass grafting (OPCABG) remains a controversial issue, but the technique has been proposed to decrease postoperative mortality and morbidity. Coronary artery bypass grafting (CABG) with a cardiopulmonary bypass carries a significant risk for patients with severe left ventricular (LV) dysfunction. OBJECTIVE The objective of this study was to compare off-pump to on-pump CABG in patients with ejection fraction (EF) lower than 30%. METHODS Prospective randomized study was carried out between June 2004 and March 2006 at the Institute for Cardiovascular Diseases of the Clinical Centre of Serbia. Sixty prospectively randomized high-risk patients divided into two groups to undergo off-pump or on-pump CABG. All recruited patients had left ventricular ejection fraction lower than 30%. RESULTS Thirty patients averaging 59.2 years of age underwent 2.30 grafts on pump, and another 30 averaging 59.6 years of age underwent 2.03 grafts off pump. OPCABG patients exhibited a significantly less release of TnI (average 0.71 micro/L) than on-pump patients (3.00 micro/L). Inotropic requirements were less in the off-pump group. The patients undergoing OPCABG received fewer units of blood and had shorter postoperative length of stay in intensive care unit and hospital stay. There was no significant difference in hospital mortality and complication rate. CONCLUSION The present study suggests that off-pump CABG in patients with poor LV function when compared with conventional CABG achieved similar number of grafts per patient, similar in-hospital outcomes, shorter length of stay, reduced transfusion requirement, and less myocardial injury.

Successful surgical treatment of terminal heart failure in the adolescent - left ventricular assist device implantation and subsequent heart transplantation

Online first: August 4, 2017 SUMMARY Introduction Implantation of the new-generation left ventricular assist device (LVAD) is an efficient therapeutic option as a bridge to transplantation in adults, as well as in children and adolescents with small body surface. The aim of this work was to present a case of a successful surgical treatment of terminal heart failure in a male adolescent who had an LVAD implanted as a bridge to heart transplantation. Case outline The patient, a 17-year-old male, was admitted with the end-stage heart failure due to the dilated cardiomyopathy and implanted LVAD. Fourteen months after LVAD implantation, a successful “second stage” surgical procedure was performed – orthotopic heart transplantation preceded by the LVAD explantation. Conclusion Long-term mechanical circulatory support is an effective and safe method in treatment of the end-stage heart failure as a bridge to transplantation in the adolescent period.

Heartmate 3 fully magnetically levitated left ventricular assist device for advanced heart failure

Introduction As the waiting time for heart transplantation continues to increase due to shortage in organ donation, supporting patients with advanced heart failure with left ventricular assist device (LVAD) increases as well. The latest generation of LVAD, left ventricular assist system (LVAS) started to expand worldwide due to more promising outcomes. The aim of this article was to present the case of treating advanced heart failure in a patient who underwent implantation of HeartMate 3 LVAS as the bridge to transplantation. Case otline The patient was a 59-year-old man with advanced heart failure requiring inotropic drug support, with ischemic cardiomyopathy as the underlying cause of heart failure. Therefore, in the absence of an adequate donor, it was decided to incorporate the LVAS as a bridge to transplantation. Functional capacity, cardiac, renal, and liver functions improved in the patient. Conclusion The use of the HeartMate 3 in an advanced heart failure patient results in improvements in functional capacity, cardiac, renal and liver function. Further studies should be performed in order to identify whether improved outcomes are sustained with a longer follow-up period.

Kinking of the Outflow Graft, Consequent Ventricular Tachycardia, and the Need for Reoperation in a Patient with Left Ventricular Assist Device

BACKGROUND Left ventricular assist devices (LVAD) have become a lifesaving solution for patients awaiting heart transplantation as well as an option to support the failing hearts of non-transplant candidates as a lifelong, or destination therapy (DT). Improvements in LVAD design have enabled greater durability and broader patient applicability, but not without complications. Ventricular arrhythmias in LVAD patients were considered benign in the early days of LVADs, but today are increasingly recognized for their harmful impact on morbidity and quality of life. CASE PRESENTATION We describe a 53-year-old male who underwent HeartWare left ventricular assist device (HVAD) implantation. During the postoperative period, the patient experienced ventricular tachycardia (VT) during a coughing episode, later found on CT to be due to significant angulation of the outflow graft. Following reoperation to shorten the outflow graft, the patient returned to hemodynamic stability, without VT or other arrhythmias. CONCLUSIONS Innovative strategies in VT prevention and improved clinical outcomes in LVAD patients may be the result of better understanding of characteristics that predispose these patients to VT. This case report showed that an excessively long outflow graft with considerable kinking created significant VT, but reoperation to correct the length of the graft mitigated further VT complications.

Three-layered ventricular septum of the helical heart: functional anatomy and clinical relevance

Results IVS displays significant fiber disarray at the boundaries of LV and RV free walls, and contains an intriguing structure that may be freshly examined by the HVMB dissection. These dissections contradict the concept that the interventricular septum belongs to the LV, since both ventricles participate in its formation. Ascending and descending segments od the HVMB provide the origin and significance of mayor “septal fiber crossing”. Conventional low resolution ultrasound imaging of the ventricular septum previously identified the border of this crossing as hyperechogenic “septal line”. We suspect the overlap of the crossing of descending and ascending segments creates this “bright line”. Histological analyses have shown that septal RV and LV fibers create a connective tissue true space. Coronary artery septal branches run through this space, a fact, which may be useful in Ross’ procedure.

Surgery for the acute dissections of the ascending aorta and the arch

Overall early mortality was 23.3% (53 pts): operative 7.5% (17 pts) and hospital 15.9% (36 pts). The early major postoperative complications were: low cardiac output syndrome 28 pts (12.3%), hemorrhage 24 pts (10.5%), focal neurological deficit 26 pts (11.4%), coma 16 pts (7.0%) and acute renal failure 12 pts (5.3%). Conclusions During this period of time, we have adopted a strategy of “the earliest possible surgery”, reducing preoperative diagnostic algorithm on carefully clinical examination and the least possible number of imaging tools. The more successful tactics of aortic dissection treatment should focus on: earlier clinical suspicion and diagnosis decrease in “onsetto-admission” time, improvements in surgical strategy/ technique and establishment of National aortic dissection registry.

Cell saver efficacy for coronary artery bypass surgery

Methods The study included sixty patients aged from 39 to 79 years presenting for CABS who were randomized to control or cell saver groups. We investigated blood parameters before and after surgery, ejection fraction, postoperative drainage, intraoperative parameters such as coronary artery bypass grafting type, number of graft, extracorporeal circulation and aortic cross clamping duration as weel as clinical complications and mortality.

Minithoracotomy as a primary alternative for LV lead implantation during coronary resynchronization therapy

Background Numerous anomalies of cardiac venous system prevent optimal endovascular implantation of LV lead in more than 15% of patients with heart failure and indications for Coronary Resynchronization Therapy (CRT). Insisting on endovenous approach in these patients can be one of the potentional reasons for large number of nonresponders reported in the literature. Purpose of this study was to analyze the results of an alternative mioepicardial approach to the stimulation of the left ventricle in CRT.

Femoral or axillary artery as a cannulation site in the acute aortic dissection type A surgery: is there still a doubt?

Background Anterograde perfusion is widely addopted strategy in aortic dissection type A treatement. Physiological blood flow direction reduces malperfusion complications during CPB and allows anterograde cerebral perfusion during circulatory arrest. In spite of these facts, femoral artery is still used as a cannulation site by surgeons worldwide. Primary end point was to analize the mortality in the two groups of patients (anterograde vs retrograde perfusion during CPB). Secondary end point was to compare frequency of postoperative complications, length of stay in ICU and in hospital.